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Biomedical subjects

Mark Olfson

Publications and source records attributed to Mark Olfson.

At least 55 records · Page 3Linked to original sources
PubMed2004

Depressed mothers coming to primary care: maternal reports of problems with their children.

BACKGROUND: Studies of depressed mothers have generally been conducted in psychiatric settings with non-minority, middle-class women. Primary care has an increasing role in early detection and treatment, especially for the poor who have less access to specialized mental health services. Data on the relationship between maternal depression and problems in the offspring in a primary care context could help physicians to more effectively identify children in need of psychiatric help. METHODS: All mothers aged 25 to 55 from a systematic sample of consecutive adults (response rate, 80%) in an urban general medicine practice were screened using the PRIME-MD Patient Health Questionnaire (PHQ). Mothers who screened positive for major depression (n=85); other psychiatric disorders, but not major depression (n=67); or no psychiatric disorders (n=191) were compared on their children's history of emotional problems, unmet need for mental health treatment, parent-child discord, maternal functional status and mental health treatment. RESULTS: Compared to non-psychiatric controls, depressed mothers reported a three-times greater risk of serious emotional problems in their children (95% confidence interval [CI], 1.7-6.1); a four-times greater risk of having their children's problems left untreated (95% CI, 2.3-8.2), and a 10-times greater risk of having poor mother-child relations within the past month (95% CI, 3.9-29.4). Depressed mothers reported more functional disability, more psychiatric treatment and more problems in their offspring than mothers with non-depressive psychiatric disorders. Although a majority of mothers (regardless of psychiatric status) believed that counseling (96%) or medication (84%) should be offered to those with serious emotional problems, only about half (49%) of the depressed mothers had received mental health treatment in the past month. LIMITATIONS: Children were not assessed directly. CONCLUSIONS: The children of low-income depressed women at a general medicine practice were reported to have a greatly increased risk for emotional problems. Many mothers had not received treatment for their own emotional problems. By enquiring about the emotional health of children of adult primary care patients, primary care providers have an opportunity to promote early detection and to facilitate appropriate treatment for both the mothers and their children.

Adult↗
PubMed2004

Major depression in community-dwelling middle-aged and older adults: prevalence and 2- and 4-year follow-up symptoms.

BACKGROUND: Although major depression is a common condition across the age range, there is some evidence from clinical studies that it may be more persistent and disabling in older adults. This study examined the demographic, socio-economic and clinical factors associated with major depression and with persistence of depressive symptoms at 2- and 4-year follow-ups in a large population sample of middle-aged and older adults. METHOD: In a sample of 9747 participants aged over 50 in the 1996 wave of the US Health and Retirement Study, the authors assessed the 12-month prevalence of major depression using the Composite International Diagnostic Interview-Short Form (CIDI-SF). Significant depressive symptoms at the time of 1996, 1998 and 2000 interviews were assessed using a short form of the Center for Epidemiological Studies Depression Scale (CES-D). RESULTS: The 12-month prevalence of CIDI-SF major depression was 6.6%. With age, prevalence declined, but the likelihood of significant depressive symptoms at follow-ups increased. Both prevalence and persistence of significant depressive symptoms at follow-ups were associated with socio-economic disadvantage and physical illness. Persistence of depressive symptoms at follow-ups was also associated with symptoms of anhedonia, feelings of worthlessness, and thoughts of death at baseline. CONCLUSIONS: Sociodemographic, physical health and a specific profile of depressive symptoms are associated with a poorer course of major depression in the middle-aged and older adults. These indicators may identify a subgroup of patients in need of more careful follow-up and intensive treatment.

Age Factors↗
PubMed2004

Use of psychotropic medications for patients with office visits who receive a diagnosis of panic disorder.

OBJECTIVE: We sought to examine trends in the medication management of panic disorder from a nationally representative sample of visits to psychiatrists and primary care physicians in office-based practice. METHOD: We analyzed physician-reported data from the 1992-1995 and 1996-1999 National Ambulatory Medical Care Survey, focusing on medication management of panic disorder by primary care physicians and psychiatrists. Rates for which doctors prescribed medication for patients with a diagnosis of panic disorder were compared over the course of time to identify changes in medication management between physician groups. We used logistic regression models to identify predictors of medication prescription, adjusting for the presence of other covariates. RESULTS: Both physician groups prescribed a psychotropic medication to a majority of patients for panic disorder in each time period. In 1992-1995, primary care physicians were less likely than psychiatrists to prescribe psychotropic medications. This difference was not evident in 1996-1999. The prescribing of benzodiazepines was common in both physician groups and time periods. Overall rates of psychotropic prescriptions by physician groups converged over time, although no single drug class accounted individually for the convergence. CONCLUSION: In recent years, changes in the medication management of patients with panic disorder by primary care physicians have resulted in greater similarity with the pharmacologic treatment of panic disorder provided in psychiatric practice.

Adult↗
PubMed2004

Delays in initial treatment contact after first onset of a mental disorder.

OBJECTIVE: To examine nationally representative patterns and predictors of delays in contacting a professional after first onset of a mental disorder. DATA SOURCES: The National Comorbidity Survey, a nationally representative survey of 8,098 respondents aged 15-54. STUDY DESIGN: Cross-sectional survey. DATA COLLECTION: Assessed lifetime DSM-III-R mental disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Obtained reports on age at onset of disorders and age of first treatment contact with each of six types of professionals (general medical doctors, psychiatrists, other mental health specialists, religious professionals, human services professionals, and alternative treatment professionals). Used Kaplan-Meier (KM) curves to estimate cumulative lifetime probabilities of treatment contact after first onset of a mental disorder. Used survival analysis to study the predictors of delays in making treatment contact. PRINCIPAL FINDINGS: The vast majority (80.1 percent) of people with a lifetime DSM-III-R disorder eventually make treatment contact, although delays average more than a decade. The duration of delay is related to less serious disorders, younger age at onset, and older age at interview. There is no evidence that delay in initial contact with a health care professional is increased by earlier contact with other non-health-care professionals. CONCLUSIONS: Within the limits of recalling lifetime events, it appears that delays in initial treatment contact are an important component of the larger problem of unmet need for mental health care. Interventions are needed to decrease these delays.

Adolescent↗
PubMed2004

Cognitive deficits and the course of major depression in a cohort of middle-aged and older community-dwelling adults.

OBJECTIVES: To examine associations between cognitive deficits and persistent significant depressive symptoms at baseline and 2- and 4-year follow-ups in a sample of community-dwelling middle-aged and older adults. DESIGN: Prospective cohort study. SETTING: A U.S. national prospective cohort study of middle-aged and older adults, the Health and Retirement Study. PARTICIPANTS: A sample of 661 participants of the 1996 wave of the Health and Retirement Study who met criteria for 12-month Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised major depression (MD). MEASUREMENTS: MD was assessed using the World Health Organization Composite International Diagnostic Interview-Short Form. Persistent significant depressive symptoms were assessed using an eight-item version of the Center for Epidemiological Studies Depression scale. RESULTS: Cognitive deficits were associated with persistent significant depressive symptoms at follow-up. In a latent state-trait analysis, two stable and strongly correlated traits best explained variations in cognitive functioning and depressive symptoms across assessment points. CONCLUSION: Trait-like cognitive deficits commonly complicate the course of MD in community-dwelling middle-aged and older adults and may help to explain the persistent course of depressive symptoms in a large subgroup of adults with MD in this age range.

Aged↗
PubMed2004

National trends in the outpatient treatment of anxiety disorders.

BACKGROUND: Recent advances in psychotherapy and pharmacotherapy have increased the number of treatment options for anxiety disorders. This article examines changes in outpatient treatment of anxiety disorders in the United States between 1987 and 1999. METHOD: Analyses are presented of service utilization data from 2 nationally representative surveys of the general population: the 1987 National Medical Expenditure Survey and the 1999 Medical Expenditure Panel Survey. Respondents were selected who made 1 or more outpatient visits for the treatment of an anxiety disorder (ICD-9/DSM-IV: 300.0, 300.2, 300.3, or 308.3). The rates of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of provider, and source of payment were determined. RESULTS: The rate of outpatient treatment for anxiety disorders increased from 0.43 per 100 persons in 1987 to 0.83 in 1999 (p <.001). Among those treated for an anxiety disorder, the proportion that received psychotropic medications increased from 52.1% to 69.9% (p =.008). Among treated patients, antidepressant use increased from 18.3% to 44.9% (p <.0001), while use of benzodiazepines (42.3% to 31.7%, p =.09) and psychotherapy (60.5% to 48.0%, p =.07) tended to decline. A decreasing proportion of mean treatment expenditures was covered by self-payment (53.2% to 31.5%, p <.0001). CONCLUSION: Between 1987 and 1999, there was an increase in the proportion of the population who received outpatient treatment for anxiety disorders. Among patients receiving care, treatment became characterized by greater use of psychotropic medications, especially antidepressant medications, with nonsignificant trends toward less common use of psychotherapy.

Adolescent↗
PubMed2004

New options in the pharmacological management of attention-deficit/hyperactivity disorder.

A brief review of the efficacy and common side effects of pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) is presented. Methylphenidate and amphetamine continue to have the strongest base of empiric support. They are both available in extended- and immediate-release preparations. Although most children with ADHD respond favorably to either medication, many children who do not respond to one medication will respond to the other. Additional pharmacological options include the nonstimulant atomoxetine, the stimulant pemoline, the antidepressants bupropion and desipramine, and the antihypertensives clonidine and guanfacine. In selecting the appropriate pharmacological regimen, consideration should be given to the child's daily school and after-school schedule, the presence of aggressive symptoms, and the risk of diversion. Careful selection of an appropriate medication regimen and active engagement of the child, parents, and teacher in daily management may help to ensure long-term adherence.

Adolescent↗
PubMed2003

Trends in care by nonphysician clinicians in the United States.

BACKGROUND: The 1990s saw rising numbers of graduates of training programs for nonphysician clinicians, passage of legislation expanding their scope of practice, and a proliferation of managed-care models that emphasized the use of these providers as a strategy for containing health care costs. METHODS: We used two nationally representative surveys to examine trends in outpatient care provided by physicians and nonphysician clinicians between 1987 and 1997, adjusting for the case mix. Analyses examined care provided by 10 categories of nonphysician clinicians: chiropractors, midwives, nurses or nurse practitioners, optometrists, podiatrists, physician assistants, physical or occupational therapists, psychologists, social workers, and others. RESULTS: Between 1987 and 1997, the proportion of patients who saw a nonphysician clinician rose from 30.6 percent to 36.1 percent (adjusted relative risk for 1997 as compared with 1987, 1.42 [95 percent confidence interval, 1.35 to 1.50]). The trend was driven by an increase in the proportion of persons who visited both a physician and a nonphysician clinician (from 23.5 percent to 30.9 percent; adjusted relative risk, 1.49 [95 percent confidence interval, 1.40 to 1.58]), rather than an increase in the proportion who saw only a nonphysician clinician (from 7.2 percent to 5.3 percent; adjusted relative risk, 0.81 [95 percent confidence interval, 0.70 to 0.93]). This pattern was consistent in analyses of specific medical conditions and specific types of nonphysician clinicians. There was an increase in the proportion of patients obtaining preventive services from nonphysician clinicians and a decline in the proportion receiving acute care services from such clinicians. CONCLUSIONS: From 1987 to 1997, there was a degree of differentiation between physicians and nonphysician clinicians with respect to the services they provided but not with respect to the patients they treated. The implications of these findings hinge on the degree to which the increase in conjoint service delivery represents growing coordination or fragmentation of care.

Adolescent↗
PubMed2003

Outpatient treatment of child and adolescent depression in the United States.

BACKGROUND: Although psychotherapy has traditionally been the dominant form of treatment for children and adolescents with depression, there has been a recent increase in the prescription of antidepressants for this age group. OBJECTIVE: To describe patterns of outpatient treatment for children and adolescents with depression. DESIGN AND SETTING: Analysis of health service-use data from 4 consecutive years (1996-1999) of the Medical Expenditure Panel Survey, a nationally representative annual survey of the general population that is sponsored by the Agency for Healthcare Quality and Research, Rockville, Md. Subjects Patients aged 6 to 18 years who made 1 or more outpatient visits for the treatment of depression. MAIN OUTCOME MEASURES: Rate of treatment, mental health problems, psychotropic medication use, psychotherapy use, number of outpatient treatment visits, and type of provider. RESULTS: Across the 4 survey years, the mean annual rate of outpatient treatment for depression was 0.93 per 100 individuals. The rate of treatment was especially low for African American individuals (0.23 per 100) and uninsured individuals (0.43 per 100). Approximately three quarters (79%) of treated children and adolescents received psychotherapy and more than half (56.9%) were prescribed antidepressant medications. The mean number of treatment visits for depression was 7.8 per year. As compared with children and adolescents with depression who were treated without antidepressants, those who received antidepressants were significantly more likely to have evidence of anhedonia, to live in large urban communities, to have parents who graduated from high school, and to have health insurance. CONCLUSIONS: The rate and pattern of treatment suggest that serious gaps exist in access to community outpatient treatment for children and adolescents with depression. At the same time, antidepressant medications are used far more commonly than would be expected on the basis of published treatment recommendations.

Adolescent↗
PubMed2003

Relationship between antidepressant medication treatment and suicide in adolescents.

CONTEXT: A decade of increasing antidepressant medication treatment for adolescents and corresponding declines in suicide rates raise the possibility that antidepressants have helped prevent youth suicide. OBJECTIVE: To evaluate the relationship between regional changes in antidepressant medication treatment and suicide in adolescents from 1990 to 2000. DESIGN: Analysis of prescription data from the nation's largest pharmacy benefit management organization, national suicide mortality files, regional sociodemographic data from the 1990 and 2000 US Census, and regional data on physicians per capita. PARTICIPANTS: Youth aged 10 to 19 years who filled a prescription for antidepressant medication and same-aged completed suicides from 588 three-digit ZIP code regions in the United States. MAIN OUTCOME MEASURES: The relationship between regional change in antidepressant medication treatment and suicide rate stratified by sex, age group, regional median income, and regional racial composition. RESULTS: There was a significant adjusted negative relationship between regional change in antidepressant medication treatment and suicide during the study period. A 1% increase in adolescent use of antidepressants was associated with a decrease of 0.23 suicide per 100 000 adolescents per year (beta = -.023, t = -5.14, P<.001). In stratified adjusted analyses, significant inverse relationships were present among males (beta = -.032, t = -3.81, P<.001), youth aged 15 to 19 years (beta = -.029, t = -3.43, P<.001), and regions with lower family median incomes (beta = -.023, t = -3.73, P<.001). CONCLUSIONS: An inverse relationship between regional change in use of antidepressants and suicide raises the possibility of a role for using antidepressant treatment in youth suicide prevention efforts, especially for males, older adolescents, and adolescents who reside in lower-income regions.

Adolescent↗
PubMed2003

Diffusion of new generation antidepressant treatment among elderly diagnosed with depression.

RESEARCH OBJECTIVE: This study analyzes the prevalence of new generation antidepressant treatment including selective serotonin reuptake inhibitor (SSRI) use from 1992 to 1997 among the elderly diagnosed with depression, using a large, nationally representative survey of Medicare beneficiaries. Relationships between use of new generation antidepressant treatment and socioeconomic characteristics, physical comorbidity, insurance coverage, and care sector (mental health specialty vs. general health services) are explored. RESEARCH DESIGN: Merged survey data, Medicare claims, and detailed self-reports from the Medicare Current Beneficiary Survey were used to explore use of new generation antidepressant treatment.SUBJECTS Medicare beneficiaries aged 65 and older living in the community, enrolled in fee-for-service Medicare throughout the year and diagnosed with depression. RESULTS: In 1997, among an estimated 1.1 million community dwelling older adults with diagnosis of depression in health care claims, nearly two thirds received antidepressant treatments. Among those diagnosed with depression and treated with antidepressants, the use of new generation antidepressants increased from 35% in 1992 to 77% in 1997. The rates of use increased among all subgroups examined. In the early years after the introduction of these new antidepressant medications (1992-1994), there were socioeconomic disparities in use of these medications, with less use by less educated and poor patients. However, these differences abated over time. CONCLUSIONS: An increasing proportion of elderly treated for depression with antidepressants received the new generation antidepressants. The diffusion of these new medications lagged for those with low socioeconomic status defined by education and income. This diffusion process conforms to a general model of diffusion in which during the initial years following introduction of a new treatment, especially one which is costly, early adopters of the treatment are likely to disproportionately represent those of higher socioeconomic status.

Age Factors↗
PubMed2003

Parental depression, child mental health problems, and health care utilization.

BACKGROUND: Small controlled studies suggest that depression and other mental health problems are more common in children of parents with depression than in children of parents without depression. OBJECTIVES: This article examines relationships between parental depression and children's mental health problems and health care utilization in a nationally representative household sample of parents and their children. RESEARCH DESIGN: Cross sectional comparisons of sociodemographic characteristics, mental health problems and health expenditures of children whose parents either do or do not report depression in the 1997 Medical Expenditure Panel Survey data. SUBJECTS: A nationally representative sample of children, 3 to 18 years of age (n = 8,360) with one or more parents living in the household. MEASURES: Mental health problems, total health expenditures, and mental health expenditures. RESULTS: Children of parents with depression were approximately twice as likely as children of parents without depression to have a variety of mental health problems and were 2.8 times more likely to use mental health services in adjusted analyses. Among children with health and mental health expenditures, those whose parents report depression had significantly higher mean total annual child health expenditures ($282 vs. $214, t = 3.5, P = 0.0006) and child mental health expenditures ($513 vs. $338, t = 2.0, P = 0.05) than children whose parents did not report depression. CONCLUSIONS: Children of parents with depression are at increased risk for a range of health problems. Parental depression is also related to an increased child health and mental health service utilization and expenditure.

Adolescent↗
PubMed2003

National trends in the treatment of attention deficit hyperactivity disorder.

OBJECTIVE: Nationally representative descriptive data were presented regarding recent trends in the outpatient treatment of attention deficit hyperactivity disorder (ADHD) in children. METHOD: Service use data were analyzed in children ages 3 to 18 years from two nationally representative surveys of the U.S. general population, the 1987 National Medical Expenditure Survey, and the 1997 Medical Expenditure Panel Survey. Trends in the rates of treatment for ADHD were presented by age, gender, race, family income, and health insurance status. Trends in ADHD treatment were also determined by annual numbers of visits, use of pharmacotherapies, and types of health care professionals. RESULTS: The rate of outpatient treatment for ADHD increased from 0.9 per 100 children in 1987 to 3.4 per 100 children in 1997. Significant increases in the rates of treatment for ADHD were evident across nearly all sociodemographic groups, with the largest increases among children from poor, near-poor, and low-income families and children ages 12 to 18. Among children who received treatment for ADHD, there was a significant decrease in the number of treatment visits but an increase in the number of stimulant prescriptions between 1987 and 1997. CONCLUSIONS: During the decade, there was a marked and broad expansion in access to treatment of children with ADHD but a decline in intensity of treatment, as measured by number of visits. These changes occurred during a period of expanding access to special education services, growth of managed behavioral healthcare, and increased public acceptance of effective psychotropic medications.

Adolescent↗
PubMed2003

Antipsychotic dosage at hospital discharge and outcomes among persons with schizophrenia.

OBJECTIVE: Applying the schizophrenia treatment guidelines established by the Patient Outcomes Research Team (PORT) project, this study evaluated whether antipsychotic medication dosage influenced patient outcomes in routine clinical settings. METHODS: The associations between discharge antipsychotic medication dosage and short-term clinical, social, and service use outcomes were observed in a sample of 246 patients with schizophrenia or schizoaffective disorder. RESULTS: Patients who were given high dosages of antipsychotic medication at hospital discharge (more than 1,000 chlorpromazine milligram equivalents) had greater severity of symptoms three months after discharge than patients who were given guideline-recommended dosages (300 to 1,000 chlorpromazine milligram equivalents) (adjusted mean Brief Psychiatric Rating Scale scores of 45 and 39, respectively). Patients who were given low dosages of antipsychotic medication at hospital discharge (less than 300 chlorpromazine milligram equivalents) were less likely to report side effects (adjusted OR=.24) and slightly more likely to be nonadherent (21 percent of those within the recommended dose range compared with 39 percent of the those with low doses, not statistically significant after Bonferroni correction). No other differences related to medication dosage were observed in patient outcomes. CONCLUSIONS: Treatment that falls within antipsychotic medication dosage guidelines is associated with improvement in a limited, but critical, range of short-term patient outcomes in routine clinical settings.

Adolescent↗
PubMed2003

Improving the detection of drug abuse, alcohol abuse, and depression in community health centers.

Up to 35 percent of primary care patients suffer from substance abuse or mental disorders, and most of these patients receive care from general medical professionals rather than mental health specialists. Accumulating evidence suggests that primary care physicians often fail to recognize, diagnose, and treat their patients with mental and substance use disorders; only about 5 percent of primary care visits result in a mental or substance use diagnosis. The goals of this project were to evaluate the feasibility of screening for drug abuse, alcohol abuse, and major depression at two federally funded urban Community/Migrant Health Centers (C/MHCs), in Newark, New Jersey, and Bronx, New York, and to examine the effects of a clinical tool designed to guide primary care clinicians in the identification and treatment of substance use and depression, assess provider perceptions of the screening form, and determine the concordance between provider and patient reports of assessment and management.

Adult↗
PubMed2002

Borderline personality disorder in primary care.

BACKGROUND: Borderline personality disorder (BPD) is a severe and chronic psychiatric disorder characterized by marked impulsivity, instability of affect and interpersonal relationships, and suicidal behavior that can complicate medical care. Few data are available on its prevalence or clinical presentation outside of specialty mental health care settings. METHODS: We examined data from a survey conducted on a systematic sample (N = 218) from an urban primary care practice to study the prevalence, clinical features, comorbidity, associated impairment, and rate of treatment of BPD. Psychiatric assessments were conducted by mental health professionals using structured clinical interviews. RESULTS: Lifetime prevalence of BPD was 6.4% (14/218 patients). The BPD group had a high rate of current suicidal ideation (3 patients [21.4%]), bipolar disorder (3 [21.4%]), and major depressive (5 [35.7%]) and anxiety (8 [57.1%]) disorders. Half of the BPD patients reported not receiving mental health treatment in the past year and nearly as many (6 [42.9%]) were not recognized by their primary care physicians as having an ongoing emotional or mental health problem. CONCLUSIONS: The prevalence of BPD in primary care is high, about 4-fold higher than that found in general community studies. Despite availability of various pharmacological and psychological interventions that are helpful in treating symptoms of BPD, and despite the association of this disorder with suicidal ideation, comorbid psychiatric disorders, and functional impairment, BPD is largely unrecognized and untreated. These findings are also important for the primary care physician, because unrecognized BPD may underlie difficult patient-physician relationships and complicate medical treatment.

Adolescent↗
PubMed2002

National trends in the outpatient treatment of depression.

CONTEXT: Recent advances in pharmacotherapy and changing health care environments have focused increased attention on trends in outpatient treatment of depression. OBJECTIVE: To compare trends in outpatient treatment of depressive disorders in the United States in 1987 and 1997. DESIGN AND SETTING: Analysis of service utilization data from 2 nationally representative surveys of the US general population, the 1987 National Medical Expenditure Survey (N = 34 459) and the 1997 Medical Expenditure Panel Survey (N = 32 636). PARTICIPANTS: Respondents who reported making 1 or more outpatient visits for treatment of depression during that calendar year. MAIN OUTCOME MEASURES: Rate of treatment, psychotropic medication use, psychotherapy, number of outpatient treatment visits, type of health care professional, and source of payment. RESULTS: The rate of outpatient treatment for depression increased from 0.73 per 100 persons in 1987 to 2.33 in 1997 (P<.001). The proportion of treated individuals who used antidepressant medications increased from 37.3% to 74.5% (P<.001), whereas the proportion who received psychotherapy declined (71.1% vs 60.2%, P =.006). The mean number of depression treatment visits per user declined from 12.6 to 8.7 per year (P =.05). An increasingly large proportion of patients were treated by physicians for their condition (68.9% vs 87.3%, P<.001), and treatment costs were more often covered by third-party payers (39.3% to 55.2%, P<.001). CONCLUSIONS: Between 1987 and 1997, there was a marked increase in the proportion of the population who received outpatient treatment for depression. Treatment became characterized by greater involvement of physicians, greater use of psychotropic medications, and expanding availability of third-party payment, but fewer outpatient visits and less use of psychotherapy. These changes coincided with the advent of better-tolerated antidepressants, increased penetration of managed care, and the development of rapid and efficient procedures for diagnosing depression in clinical practice.

Adult↗